** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018 Northwestern Memorial Hospital SUGGESTED EMPIRIC ANTIMICROBIAL THERAPY BY SITE OF INFECTION Empiric antimicrobial guidelines are based on the most likely organisms responsible for infection, NMH susceptibilities, and prevalence of resistant organisms. Therapy may need to be adjusted once identification and susceptibility are determined. Previous antimicrobial therapy may affect the susceptibility of organisms that subsequently cause infection. Close attention should be given to courses of antimicrobial therapy administered to patients in the recent past. In many cases, obtaining the appropriate specimen(s) before antibiotics are started is critical to successful outcomes of an infectious disease. Alterations in empiric antimicrobial therapy may be required. Anatomic site /diagnosis Common Pathogens Preferred therapy Alternative** Comments Bone Acute osteomyelitis Staphylococcus aureus (MSSA and MRSA) vancomycin Bone biopsy and/or tissue biopsy is strongly recommended prior to starting antibiotics if patient is hemodynamically stable. Acute osteomyelitis in patient with hemoglobinopathy (Sickle cell disease or Thalassemia) Salmonella spp., other Gram-negatives, S. aureus ceftriaxone +/- vancomycin ciprofloxacin +/- vancomycin Bone biopsy and/or tissue biopsy is strongly recommended. Fluoroquinolone resistance is increasingly reported among Salmonella spp. Long bone status post internal fixation of fracture S. aureus, Staphylococcus epidermidis , Gram-negatives vancomycin + cefepime Bone biopsy and/or tissue biopsy is strongly recommended. Sternum, post- operative S. aureus, S. epidermidis vancomycin Bone biopsy and/or tissue biopsy is strongly recommended. Vertebral osteomyelitis +/- epidural abscess S. aureus most common (including MRSA), other Gram-positives and Gram-negatives also possible vancomycin + ceftriaxone, OR vancomycin + cefepime if risk factors for Pseudomonas aeruginosa vancomycin + fluoroquinolone OR daptomycin +/- fluoroquinolone Obtain blood cultures in non- surgery-associated cases. Bone biopsy and/or tissue biopsy is strongly recommended. In patient with acute neurologic compromise, sepsis, or hemodynamic instability, ok to start empiric treatment prior to collecting bone or tissue cultures. IDSA Native Vertebral OM guidelines
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Bone · Peritonitis--Peritoneal Dialysis Gram related S. aureus, S. epidermidis, -negatives, Candida spp. vancomycin + cefepime Contact ID pharmacist on call
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** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Northwestern Memorial Hospital SUGGESTED EMPIRIC ANTIMICROBIAL THERAPY BY SITE OF INFECTION
Empiric antimicrobial guidelines are based on the most likely organisms responsible for infection, NMH susceptibilities, and prevalence of
resistant organisms. Therapy may need to be adjusted once identification and susceptibility are determined.
Previous antimicrobial therapy may affect the susceptibility of organisms that subsequently cause infection. Close attention should be given to
courses of antimicrobial therapy administered to patients in the recent past. In many cases, obtaining the appropriate specimen(s) before antibiotics are started is critical to successful outcomes of an infectious disease. Alterations in empiric antimicrobial therapy may be required.
Anatomic site /diagnosis
Common Pathogens Preferred therapy Alternative** Comm ents
Bone Acute osteomyelitis Staphylococcus aureus
(MSSA and MRSA) vancomycin Bone biopsy and/or tissue biopsy
is strongly recommended prior to
starting antibiotics if patient is
hemodynamically stable. Acute osteomyelitis in patient with hemoglobinopathy (Sickle cell disease or Thalassemia)
Salmonella spp., other
Gram-negatives, S. aureus ceftriaxone +/- vancomycin ciprofloxacin +/-
vancomycin Bone biopsy and/or tissue biopsy is strongly recommended. Fluoroquinolone resistance is
increasingly reported among Salmonella spp.
Long bone status post internal
fixation of fracture
S. aureus, Staphylococcus epidermi dis,
Gram-negatives
vancomycin + cefepime Bone biopsy and/or tissue biopsy is strongly recommended.
Sternum, post-operative
S. aureus, S. epidermidis vancomycin Bone biopsy and/or tissue biopsy is strongly recommended.
Vertebral osteomyelitis +/-
epidural abscess
S. aureus most common (including MRSA), other
Gram-positives and
Gram-negatives also
possible
vancomycin + ceftriaxone, OR vancomycin + cefepime if risk factors for Pseudomonas aeruginosa
vancomycin +
fluoroquinolone OR daptomycin +/-
fluoroquinolone
Obtain blood cultures in non-surgery-associated cases. Bone biopsy and/or tissue biopsy is strongly recommended. In patient with acute neurologic
compromise, sepsis, or hemodynamic instability, ok to start empiric treatment prior to collecting bone or tissue cultures. IDSA Native Vertebral OM guidelines
Empiric antibiotics are indicated prior to LP if acute bacterial meningitis is suspected. Penicillin testing necessary with Beta-lactam allergy; contact infectious diseases and allergy services. If pneumococcal meningitis suspected, administer dexamethasone before or with first dose of antibiotics: Dexamethasone 10mg IV q 6 hours x 2-4 days.
If S. pneumoniae is ruled out as cause, discontinue dexamethasone. IDSA Bacterial Meningitis Guidelines † Ampicillin or trimethoprim- sulfamethoxizole is given to
cover Listeria monocytogenes, more common in patients over age 50, alcoholics, pregnant
women, and patients with impaired cellular immunity.
Meningitis--post-surgical or post traumatic
S. aureus, S. epidermi dis , Gram-n egati v es
vancomycin + cefepime (preferred)
For true PCN allergy:
vancomycin +
meropenem
Brain abscess--
primary S. pneumoniae, Streptococcus
spp., Bacteroides spp., Enterobacteriaceae, S. aureus
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Healthcare-associated or
severely ill: same as high-risk
community-acquired
piperacillin/tazobactam If patient has any of the following: post-op infections, recent cephalosporins use, immuncompromised, valvular heart disease or prosthetic intravascular material consider adding vancomycin
aztreonam +
metronidazole +
vancomycin
Both preferred and alternative therapies provide empiric Enterococcal coverage
(directed at E. faecali s ). E.
faecali s coverage is
recomm end ed, especially for
those with post-op infection,
those who have previously
received cephalosporins,
immunocompromised patients,
and those with prosthetic
intravascular material.
Following appendectomy, no
perforation
none none Surgical prophylaxis only
Following appendectomy, with
perforation
Enterobacteriaceae,
Bacteroides spp.
ceftriaxone + metronidazole
aztreonam +
metronidazole
Hepatic abscess Enterobacteriaceae,
Bacteroides spp., Enterococcus spp.
ceftriaxone + metronidazole
Blood cultures are recommended. Diagnostic aspiration and/or drainage is
often indicated. Consider serologic testing for amoebiasis (Entamoeba histolytica antibody
IgG)
Pancreatitis--acute/non-
necrotizing
noninfectious No antibiotic therapy necessary
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
For patients with documented
GC or Chlamydia, sexual
partners within prior 60 days need
medical evaluation and
treatment.
CDC STI Guidelines
HEART
Endocarditis Refer to guidelines or Optimizer
ID consult recommended. Refer to AHA guidelines: IDSA/ AHA Endocarditis
Management guidelines
JOINT
Septic joint/ at risk for
STI
At risk for sexually transmitted infection (STI): Neisseria gonorrhoeae, S. aureus, Streptococcus spp., rarely
enteric Gram-negative bacilli
ceftriaxone +/- vancomycin
aztreonam + vancomycin
Send blood cultures before antibiotics are started. Early joint aspiration is strongly recommended for cell count,
differential, gram stain, crystals, and culture to guide diagnosis. For type-1 penicillin allergy, consult Infectious Diseases and Allergy. If gonorrhea is suspected, cultures from the joint may or may not be positive.
Septic Joint- not at risk for STI
S. aureus (MSSA and MRSA), Streptococcus spp., Gram-negative bacilli
vancomycin + ceftriaxone vancomcyin + aztreonam
Prosthetic joint infection
S. aureus (MSSA and MRSA),
S. epidermi di s , Streptococcus spp., rarely Gram-negative
bacilli
vancomycin See 2013 IDSA Guideline for Prosthetic Joint Infections: IDSA Prosthetic Joint Guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
KIDNEY, BLADDER AND PROSTATE Asymptomatic bacteriuria
E. coli , Enterobacteriaceae,
Should only be treated in pregnant women or patients
undergoing urologic procedures with anticipated mucosal bleeding --other patients should be evaluated on a case-by-case basis. See IDSA guidelines for asymptomatic bacteriuria: IDSA Asymptomatic Bacteriuria Guidelines
Cystitis E. coli , Enterobacteriaceae, S.
saprophyticus
nitrofurantoin (if estimated creatinine clearance >30 mL/min); cephalexin or IV cefazolin (reserved for
those who are unable to swallow pills
trimethoprim-
sulfamethoxaz
ole or
ciprofloxacin**
Consider testing urethritis for gonorrhea, chlamydia, and trichomonas. IDSA Uncomplicated Cystitis\Pyelo Guidelines
Complicated UTI/catheters
E. coli, Enterobacteriaceae,
cefazolin
May consider
alternative therapy based on patient’s history of urinary
pathogens
See IDSA guidelines for
catheter-related UTIs (recommended to d/c or change catheter)
IDSA Catheter Assoc UTI Guidelines
Asymptomatic Candiduria (Treat ONLY patients who are at high risk for dissemination, such as neutropenic patients, low birth weight infants <1500 g, and patients
who will undergo urologic manipulation)
Candida spp.
Remove catheter
Neutropenic patients and very low–birth-weight
infants should be treated as recommended for candidemia (see below)
Patients undergoing
urologic procedures should be treated with oral fluconazole, 400 mg (6
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Symptomatic Candiduria
C. albicans (and other fluconazole susceptible spp)
Remove catheter, fluconazole See IDSA guidelines for candidiasis, IDSA Candidiasis Guidelines Micafungin, liposomal Ampho and voriconazole have poor renal excretion and are NOT considered effective against fungal UTI
Fluconazole-resistant Candida spp
Page ID Pharmacist for alternatives
Pyelonephritis--acute,
uncomplicated
E. coli, Enterobacteriaceae Cefazolin Aztreonam (severe, confirmed beta-lactam allergy)
NMH urinary antibiogram shows similar (>90% susceptibility) of ceftriaxone and cefazolin.
Increasing rates of
ciprofloxacin- resistance among
Enterobacteriaceae have been
noted. See IDSA guidelines for
uncomplicated
UTIs/pyelonephritis,
IDSA Uncomplicated
Cystitis\Pyelo Guidelines
Pyelonephritis, with sepsis
Enterobacteriaceae,
cefepime +/- amikacin aztreonam + amikacin
+\- vancomycin
(severe, confirmed beta-lactam allergy)
Patients at increased risk of enterococcal infections: elderly, urinary obstruction and post
instrumentation; septic patients with these risks may benefit from empiric E. faecalis coverage
(i.e., piperacillin-tazobactam). Also, review prior urinary isolates for antibiotic resistance.
Perinephric abscess Enterobacteriaceae piperacillin/tazobactam Recommend drainage of larger abscesses, may need aspiration for microbiologic diagnosis.
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Not neutropenic, no hypotension, source unclear
S. aureus (MSSA and MRSA),
Streptococcus spp., E. coli vancomycin + ceftriaxone Consider adding empiric
doxycycline, particularly if recent exposure to woodlands, ticks, or
developing countries.
Not neutropenic, no hypotension,
suspect intra-abdominal source with
mild to moderate severity
Enterobacteriaceae Ceftriaxone + metronidazole
aztreonam +
metronidazole + vancomycin
(severe, confirmed beta-lactam allergy)
For patients with sepsis of high severity, see recommendations under Septic Shock.
Not neutropenic, no hypotension,
petechial rash
S. pneumoniae, N. meningitidis ceftriaxone + vancomycin Consider adding empiric
doxycycline, particularly if recent exposure to woodlands, ticks, or developing countries.
Not neutropenic, no hypotension,
suspect urinary source
Enterobacteriaceae,
Enterococcus spp.
piperacillin/tazobactam
aztreonam
Fever & neutropenia (no hypotension, no apparent source) in a cancer patient receiving chemotherapy
Enterobacteriaceae,
Pseudomonas aeruginosa.
cefepime vancomycin +
aztreonam (severe, confirmed
beta-lactam allergy)
Empiric vancomycin is unnecessary unless patient is hemodynamically unstable, has pneumonia or PCN allergy, severe mucositis, or there is evidence of catheter-related infection on exam. Discontinue vancomycin after 72
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Fever & neutropenia -- febrile longer than 96 hours
as above (fever & neutropenia) + fungal infection
add micafungin Micafungin has broad coverage for Candida spp. It is not the preferred antifungal agent for all cancer patients, however, as this drug does not treat Aspergillus spp. or Mucor spp. High risk cancer patients are considered at increased risk of mold infections. For more information, see:
Incision and drainage is the primary treatment. Antibiotic therapy is needed only if associated fever or systemic infection or if extensive surrounding cellulitis is present: trimethoprim- sulfamethoxazole or
doxycycline
clindamycin Hot packs, incision and drainage serves as primary therapy. If incision and drainage is performed, sampling for culture and sensitivity is beneficial. Note: clindamycin resistance is present in > 50% of MRSA isolates. See IDSA SSTI
Guidelines Cellulitis Non-purulent: Group A
Streptococcus spp., Group
B, C, G Streptococcus
spp
(S. aureus i s uncommon in
absence of abscess, necrosis,
or purulent drainage.)
cefazolin clindamycin See Antibiotic Resources for
NMH guidelines (Skin and Soft tissue Infection Treatment Algorithm)